Located in the heart of the Coachella Valley, you have access to resort-style living and world-class amenities throughout Southern California.
Job Objective:
Uses skilled intervention and clinical best practice to concurrently screen admission review and review with payors in collaboration with Case Management for utilization issues. In addition, the UR LVN will disseminate information to improve service to patients/members, their families, and all staff members. Will do UR and enter data in EPIC.
Job Description:
Education:
Required: Graduate of an accredited Licensed Vocation Nurse Program if hired after March 1, 2025
Licensure/Certification:
Required: California Licensed Vocational Nurse (LVN)
Experience:
Preferred: Three (3) years of LVN or Case Management experience
Essential Responsibilities:
- Demonstrates compliance with Code of Conduct and compliance policies, and takes action to resolve compliance questions or concerns and report suspected violations.
- Ensures appropriate authorization for commercial patients.
- Serves as the first line responder to payor’s clinical questions and for approval for admission, per established process. Manages the payor line appropriately.
- Ensures appropriate demographic information has been communicated and pre-certification/verification obtained.
- Contacts UR Nurse when requests for reviews come in.
- Completes Medical Necessity reviews, documenting in electronic medical record according to established policies and procedures
- Calls, faxes or electronically transmits reviews to payors.
- Ensures authorization information is being communicated to the business office, per established processes.
- Keeps attending physician updated and aware of authorization status. Notifies attending physician of any change in authorization status.
- Follows up with payors to obtain authorization, after discharge
- Enters all appropriate authorization issues for follow-up.
- Tracks any outstanding authorization issues for follow-up.
- Provides notification of discharges to insurance payors.
- Notifies the UR Nurse and Denials Coordinator of potential denials.
- Supports the denials coordinator to manage retrospective appeals and documents according to established policy.
- Coordinates physician reviews with the UR Nurse, inpatient case manager and appropriate physicians for the denials management process.
- Performs other duties as assigned.
Essential Skils:
- Written and verbal communication skills
- Ability to analyze situations accurately and takes effective action
- Self-motivated, self-starter, and able to organize efforts around helping clients have a positive experience
- Understanding of and compliance to patient confidentiality requirements and the related legal and ethical issues
- Computer literate in EPIC, Microsoft Word, Windows and Excel
- Ability to exercise a high degree of initiative, judgment, and discretion
- Understanding and working knowledge about notices of non-coverage/denial letters to patients including Medicare/HSAG, federal and state and guidelines
- Knowledge of the various health care delivery systems and payer prior approval requirements
- Working knowledge of Interqual criteria
- Knowledge of regulations, standards and legislation (local, state and federal) related to the continuum of care and patient transition
- Working knowledge of Medi-Cal, Medicare/HSAG, state and federal guidelines and managed care healthcare systems
